Examining the Impact of a Population-Based Intervention on Children's Physical Activity Levels: The Grade 5 ACT-i-Pass Program in London, Ontario

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Western University Western University

Scholarship@Western

Electronic Thesis and Dissertation Repository

3-21-2017 12:00 AM

Examining the Impact of a Population-Based Intervention on

Children's Physical Activity Levels: The Grade 5 ACT-i-Pass

Program in London, Ontario

Christine E. Smith

The University of Western Ontario Supervisor

Dr. Jason Gilliland

The University of Western Ontario Graduate Program in Geography

A thesis submitted in partial fulfillment of the requirements for the degree in Master of Science © Christine E. Smith 2017

Follow this and additional works at: https://ir.lib.uwo.ca/etd

Part of the Human Geography Commons, and the Maternal and Child Health Commons

Recommended Citation Recommended Citation

Smith, Christine E., "Examining the Impact of a Population-Based Intervention on Children's Physical Activity Levels: The Grade 5 ACT-i-Pass Program in London, Ontario" (2017). Electronic Thesis and Dissertation Repository. 4427.

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Abstract

Childhood obesity is a major public health concern caused in part by decreasing levels of

physical activity (PA). Identification of effective population level strategies for increasing

children’s PA levels is critical for improving overall health. This thesis is comprised of two

studies. Study 1 examines how naturally-occurring population-level PA interventions with

children have been evaluated in previous studies by conducting a systematic review. A total of

15 papers were included for review and results suggest that naturally-occurring population-based

PA interventions are generally effective in improving PA levels of children in a variety of PA

domains. Eleven studies included additional evaluation components to help justify results and

provide important contextual information. Using an ecological framework, Study 2 investigates

how the provision of a naturally-occurring population-based PA intervention in London, Ontario

impacted children’s PA levels. A total of 643 children completed baseline and post-intervention

surveys. Results showed a significant increase in PA over time, with significant increases for

girls, visible minorities, children born outside of Canada, children with low parental support, and

children from all neighbourhood SES groups. Sex and parental support were the only significant

predictors of change in PA. Examining naturally-occurring population-based PA interventions is

a beneficial opportunity that should be used by researchers to provide real-world evidence of

effective strategies to assess and increase children’s levels of PA.

Keywords

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Co-Authorship Statement

Both integrated articles within this thesis will be submitted for publication in

peer-reviewed journals. Chapter 2 and Chapter 3 are my original work, with Dr. Jason Gilliland, Dr.

Andrew Clark and Dr. Piotr Wilk as co-authors on Chapter 3. I am the primary author and

performed all data collection, analysis, and writing of each article. Dr. Jason Gilliland designed

the evaluation of the ACT-i-Pass study, and Dr. Gilliland, Dr. Clark, and Dr. Wilk were involved

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Acknowledgements

I would first and foremost like to thank my supervisor, Jason Gilliland. Your knowledge,

passion, and experience within academia allowed me to develop my research abilities and gain

invaluable skills, which I will always be grateful for.

Dr. Andrew Clark, it has been a pleasure working with you on the ACT-i-Pass project

since I started at the HEAL in 2014. You have been such a patient mentor during my time as a

graduate student and I don’t know what I would have done without your support, guidance and

good humour. I have learned so much from you.

Christine Mitchell and Sarah McCans, no words can describe how appreciative I am to

have had the support from both of you throughout this process. You both helped me through the

difficult times I experienced on this journey and I don’t know what I would have done without

your encouragement and friendship.

To all my lab mates, it has been a pleasure working alongside all of you for the past two

years. It is through this supportive environment that we are able to all succeed, and for that, I am

truly thankful. I would like to thank all our community partners in the ACT-i-Pass project and all

the students, parents, teachers, principals and school staff that participated in the project. I would

like to acknowledge the field work leaders who helped with this project, especially Sabrina Sater,

Christine Mitchell, Joannah Campbell; and more than 20 additional undergraduate research

assistants for there time and dedication to this project.

Finally, to my family and friends, thank you for all the love and support you have given

me. You have all patiently listened to my rants, been there throughout the difficult times, and

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List of Tables

Table 1.1 Prominent theories in physical activity research provided by Buchan et al. (2012) &

Glantz et al. (2008). ... 6

Table 2.1 General characteristics of the papers reviewed. ... 31

Table 2.2 Measurement characteristics of the reviewed papers ... 33

Table 2.3 Results of the reviewed papers by physical activity domain ... 34

Table 2.4 Integrated review table with data extracted from articles examining naturally-occurring population-level PA interventions with children ... 59

Table 3.1 Characteristics of the Study Participants (n=643) ... 79

Table 3.2 Average differences in self-reported PA from baseline to post-intervention by subgroups (n=643) ... 81

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List of Figures

Figure 1.1 Ecological model adapted from Mitchell et al. (2016) & Sallis et al. (2006) ... 8

Figure 2.1 Systematic Review Flow Chart ... 28

Figure 3.1 Location of elementary schools and facilities participating in the ACT-i-Pass

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List of Appendices

Appendix A Location of Schools and Facilities Participating in the ACT-i-Pass Program ... I

Appendix B Recruitment Letter ... II

Appendix C ACT-i-Pass Child Survey ... IV

Appendix D ACT-i-Pass Parent Survey ... XI

Appendix E Physical Activity Questionnaire for Children (PAQ-C) ... XVII

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Introduction

Research Context

Over the last 25 years, the dramatic increase in obesity rates among children and

adolescents has become a major public health concern in Canada (Chaput et al., 2012; Colley et

al., 2011; Janssen et al., 2005). According to Statistics Canada (2015), almost one third of

children and youth ages 5 to 17 years are classified as overweight or obese. While

epidemiological studies show a steady trend in the rate of overweight and obesity in youth

(Allison et al., 2015; Roberts et al., 2012), disparities between socioeconomic and ethnic groups

are growing (Singh et al., 2010).

Obesity is the result of a sustained energy imbalance from an increase in energy intake

and/or decrease in energy expenditure (Hill et al., 2012); however, understanding the complexity

of this energy imbalance is a continued challenge. Childhood obesity is problematic for a number

of reasons, primarily the several negative consequences related to physical health, mental health,

quality of life and longevity (Gurvinder et al., 2012; Halfon et al., 2013; Jansen et al., 2013;

Must et al., 1999; Schwimmer et al., 2003). Numerous clinical studies have confirmed a link

between childhood obesity and cardiovascular disease, hypertension, type II diabetes mellitus,

metabolic syndrome, orthopaedic issues, asthma, fatty liver disease and gastrointestinal diseases

issues (Must et al., 1999; Reilly et al., 2011; Pulgarón et al., 2013). In addition to the

health-related outcomes, obesity is associated with a plethora of negative psychological outcomes

including low self-esteem, body dissatisfaction, social isolation, anxiety, and depressive

symptoms (Puder & Munsch, 2010;Pulgarón et al., 2013; Wardle & Cooke, 2005).

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address this health issue. Physical activity (PA) is one such lifestyle factor that can directly

impact the obesity levels of children by increasing energy expenditure. Engaging in regular PA

during childhood protects against the risk factors associated with obesity (Janssen & LeBlanc,

2010; Shaibi et al., 2008). PA is also associated with psychological and social benefits such as

improved academic performance, higher self-esteem, enhanced social support and reduced

depressive symptoms (Trudeau & Shephard, 2010; Piko et al., 2006). Despite the benefits, a

majority of children do not engage in enough PA, as only 9% of Canadian children (age 5-17)

meet Canada’s recommended guidelines of 60 minutes of moderate-to-vigorous intensity on

most days of the week (ParticipACTION, 2016).

The overarching purpose of this thesis is to contribute to our understanding of the

determinants of children’s PA levels. More specifically, this thesis focuses on population-level

interventions designed to increase children’s PA. The aim is to provide a comprehensive

understanding of factors that may impact children’s PA, in addition to contributing research to

develop more effective intervention strategies based on the findings.

Reasons for not engaging in physical activity are complex, as the behaviour is highly

variable and influenced by multiple factors at different levels (Sallis et al., 2006). A number of

socio-demographic factors (age, ethnicity, sex, SES and immigrant status) have been identified

as underlying determinants of PA in children (Brodersen et al., 2007; Bryan et al., 2006; Colley

et al., 2011; Mitchell et al., 2016; Sallis et al., 2000; Singh et al., 2008). Patterns of decline in PA

show that age is a critical factor (Sallis et al., 2000), as many studies suggest that PA declines

rapidly from childhood to adolescence, with more dramatic decreases for females (Brodersen et

al., 2007; Canadian Fitness & Lifestyle Research Institute [CFLRI], 2010; Colley et al., 2011;

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genders showed a reduction in PA levels and an increase in sedentary behaviours beginning at

age 11 (Brodersen et al., 2007). Intervening during this stage of development and establishing

active lifestyles early is crucial in order for PA habits to persist into adulthood (Telama et al.,

2005). While PA levels have been shown to be low for Canadian children in general (Colley et

al., 2011), certain sub-groups of children and recent immigrants face an increased risk for

insufficient activity levels (Brodersen et al., 2007; Bryan et al., 2006; Gordon-Larsen et al.,

1999; Singh et al., 2008)

In addition, several social factors are suggested to influence children’s PA. Social support

from parents and peers demonstrate positive effects on children’s PA (Beets et al., 2006; Barkley

et al., 2014; Duncan et al., 2005). Several studies suggest that parents positively influence their

children’s PA through supportive actions, such as encouraging children to play, providing

transportation to PA opportunities, watching children participate in activities and actively

engaging with children (Beets et al., 2006; Duncan et al., 2005; Sallis et al., 2000; Trost &

Loprinzi, 2011; Welk, Wood, & Morss, 2003). Similarly, research on peer support suggests that

the presence and supportive actions from friends improves physical levels (Duncan et al., 2005;

Salvy et al., 2009). Although the presence of social support positively impacts children’s activity

levels, inconsistencies exist in terms of methods used to assess social support and what types of

supportive actions are related to increased PA levels (Beets et al., 2010; Sallis et al., 2000)

On a broader scale, numerous studies have linked supportive neighbourhood environments

(e.g., parks and recreational facility proximity) to increased PA behaviour (Davison & Lawson,

2006; Giles-Corti & Donovan, 2002; Mitchell et al., 2016; Norman et al., 2006; Powell et al.,

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2003; Gordon-Larsen et al., 2006; Mitchell et al., 2016; Roemmich et al., 2006; Tucker et al.,

2009; Powell et al., 2007). Gordon-Larsen and colleagues (2006) found that youth who lived in a

neighbourhood with one recreational facility were more likely to engage in 5 or more bouts of

moderate-to-vigorous PA per week. The presence of recreational facilities may depend on the

socio-economic status (SES) of the neighbourhood, as research suggests that individuals who

live in low and medium SES neighbourhoods had fewer PA resources (i.e., areas used for PA

such as parks, community centers, dance studios) available and fewer free PA opportunities,

compared to high SES neighbourhoods (Estabrooks et al., 2003; Gorden-Larsen et al., 2006).

Intervention Studies

The multiple factors that influence children’s PA underscore the need to develop effective

interventions to modify these factors. Interventions are an effective tool for testing current

understandings and learning from the action taken in order to identify effective strategies that

improve children’s PA (Hawe & Potvin, 2009).

A growing number of studies are examining the effectiveness of community-based

interventions to promote children’s PA. Children spend a considerable amount of time outside of

school and community-based interventions provide an opportunity to research children in their

natural environment by increasing PA opportunities within the community (Brand et al., 2014;

van Sluijs et al., 2011; Perry et al., 2012; Sallis et al., 2008). Community-based interventions are

desirable as they allow for a greater reach of the targeted population, pooled resources to

enhance interventions (Bopp & Fallon, 2008), and have the potential to achieve population-level

change in PA levels (Sallis et al., 2008). Current research suggests that the most effective and

sustainable PA interventions involve large-scale collaboration among multiple sectors of the

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Sallis et al., 2008). While large-scale collaborations are effective, they can be challenging to

organize, as it requires the coordination of many different groups in order to develop, implement

and evaluate an intervention (Bopp & Fallon, 2008).

Most researchers are not in a position to develop community-level interventions

independently, partly due to the resources (i.e., time, cost, administration, staff) needed to

conduct an intervention at the population-level. To bypass this issue, researchers can take

advantage of already occurring community-based interventions and evaluate them as a ‘natural

experiment.’ A natural experiment can be used to evaluate interventions where individuals in

experimental conditions are determined by nature or other factors outside the control of the

researchers (Craig et al., 2012; Petticrew et al., 2005). Natural experiments can also be referred

to as occurring’ interventions. The terms ‘natural experiment’ and

‘naturally-occurring’ are used interchangeably throughout the thesis, as the terms both represent

interventions that are initiated by an external agency and are not under the direct control of

researchers.

Natural experiments allow researchers to evaluate population-level PA interventions that

may not be possible as a controlled experiment and provide evidence of real-world effectiveness

(Petticrew et al., 2005). Although natural experiments have potential to evaluate population-level

change, they are not frequently used in PA interventions with children (Petticrew et al., 2005).

Theoretical Framework

In the past, theories and frameworks largely focused on the social influences and

psychological mechanism that impact PA behaviour. PA research and practice has been guided

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Self-Determination Theory, and Transtheoretical Model (Buchan, Ollis, Thomas, Baker, 2012). A

brief description of each theory can be found in Table 1.1.

Table 1.1 Prominent theories in physical activity research provided by Buchan et al. (2012) & Glantz et al. (2008).

Name of Theory or Framework Description

Social Cognitive Theory Social Cognitive Theory suggests that behaviour, cognition, and other personal features have reciprocal relationships with environments. When predicting behaviour, self-efficacy has been found as the most powerful factor to consider.

Theory of Planned Behaviour Theory of Planned Behaviour builds upon the Theory of Reasoned Action and posits that the most important predictor of behaviour is behavioural intention. Intention is a determinant of one’s attitude, subjective norms and perceived control over performing the behaviour

Self-Determination Theory Self-Determination Theory focuses on how a person attains the motivation for starting new health behaviours and maintaining them. This theory states that human behaviour is driven to meet three basic needs: competence, autonomy, and relatedness. Behavioural outcomes will occur when these three basic needs are met.

Transtheoretical Model Behaviour change has been characterized as a five-stage process or continuum related to a person’s readiness to change: pre-contemplation, contemplation, preparation, action and maintenance. Each stage is characterized by different psychosocial and behaviour changes.

Although these theories and frameworks present different features, the core purpose is

focused on changing individual behaviour. The application of these theories has greatly

enhanced our understanding of key psychological influences and processes related to PA

behaviour (Buchan et al., 2012). A number of effective PA interventions have used these

theories, though little has changed in terms of PA outcomes for children (Buchan et al., 2012).

The focus on individual change limits the long-term maintenance of the behaviour (Bock et al.,

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population-wide impact, as other sources of influence (i.e., social support, community, built environment)

are not considered (Sallis et al., 2008).

Recently, there has been a growing interest towards the application of ecological models in

PA research and practice, due to their ability to guide comprehensive population-wide

approaches to changing PA behaviours (Sallis et al., 2008). Ecological models of health address

a behaviour using a range of factors across multiple levels of influence including intrapersonal

(i.e., sex, age, attitudes), interpersonal (i.e., social support, household income), community,

physical environment, and policy (Sallis et al., 2008) (see Figure 1.1).

When developing comprehensive interventions to target PA, ecological models provide a

useful approach as they systematically assess mechanisms of change at the multiple levels of

influence. While this approach is relevant for population-level interventions, it is also useful for

addressing how place interacts with behaviour. PA occurs in specific places and the ecological

model provides a framework to identifying the characteristics of places that facilitate or hinder

PA (Sallis et al., 2006; Sallis et al., 2008). For these reasons, an ecological model of health

guides this thesis in order to develop a more thorough understanding of the multiple levels of

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Figure 1.1 Ecological model adapted from Mitchell et al. (2016) & Sallis et al. (2006)

Research Objectives

The overarching objective of this research is to contribute to a growing body of literature

assessing the effectiveness of population-based PA interventions with children. This research

aims to better understand how naturally-occurring population-based interventions influence

children’s PA and what other factors promote or hinder children’s PA. This understanding is

necessary to develop effective strategies, guide future intervention and inform policy-makers

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To achieve these objectives, this research uses both primary and secondary data. First,

secondary literature will be used to conduct an integrative review to address the following

research question:

(1) How have naturally-occurring population-based PA interventions with children been

evaluated in previous studies?

Primary data will then be used to evaluate a population-level PA intervention to address the

following research question:

(2) How does the provision of a naturally-occurring population-level intervention change

children’s level of PA over time in London, ON?

To answer the first research question, this study draws data from existing literature to

identify articles that examine naturally-occurring population-level PA interventions with children

to determine how these studies are being evaluated and what methods and measures are used.

This review aims to summarize and evaluate previous literature by identifying gaps in current

research, identifying prominent issues in the studies, and exploring which methods and measures

have been used successfully.

To address the second research question, this study draws data from a city-wide initiative

launched by London’s Child and Youth Network (CYN) called the Grade 5 ACT-i-Pass project

(ACT-i-Pass). London, Ontario is a mid-sized Canadian city located in Southwestern Ontario

with approximately 366,151 inhabitants, 23% of whom (84,080) were 19 years of age or younger

according to the 2011 Census of Canada (Statistics Canada, 2012). The ACT-i-Pass program

developed by the CYN (www.londoncyn.ca) provided all grade five children in the City of

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study used a longitudinal cohort design to evaluate the impact of a naturally-occurring

intervention on children’s PA levels (Gilliland et al., 2015). During the study period, participants

were recruited to register for the program and parental consent was provided to those students

who took part in the research portion. Data collection comprised of four measurement periods

over an 18-month period in which children and parents completed self-report questionnaires

about their socio-demographics (i.e., sex, age, race, family composition), postal code, leisure

time activity, PA levels, barriers to PA, perceived accessibility to and use of recreational

facilities in their neighbourhood, and perceived parental and peer support. This thesis focuses

specifically on two measurement periods (baseline and post-intervention), approximately a

12-month period between each questionnaire. Methods are explained in greater detail in each

integrated article (Chapter 2 and Chapter 3).

PA remains a complex health behaviour influenced by a range of factors across multiple

levels (i.e., intrapersonal, interpersonal, community, environment). Accordingly, this thesis

hypothesizes that factors at each of these levels may impact the success of interventions and

therefore seeks to understand the factors that are associated with change in children’s PA. This

research accounts for several variables known to influence PA occurring at the individual-,

social- and neighbourhood-level.

Thesis Format

This thesis follows an integrated article format, comprised of two independent but related

studies. Both studies examine how naturally-occurring population-based PA interventions

influence children’s PA levels. While each study has the same overarching objective, the specific

objectives are met using different approaches. The first study aims to provide insight on how

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intervention in London, Ontario. In doing so, this thesis aims to provide more knowledge of

effective population-level PA interventions with children. Brief descriptions of each thesis

chapter are provided below.

Chapter 2 reviews existing literature examining naturally-occurring population-level PA

interventions with children by conducting a systematic review. This review identifies the current

methods and measures used to evaluate PA, identifies successful and unsuccessful components

of the studies, and what external factors influence PA outcomes.

Chapter 3 examines how the provision of a naturally-occurring population-level PA

intervention changes children’s level of PA over time in London, Ontario. This study addresses

whether the intervention was successful in improving children’s PA levels, examines differences

in pre- and post-intervention PA in subgroups of children, and investigates individual, social and

neighbourhood characteristics that predict PA change.

Chapter 4 summarizes and connects the findings from each integrated article. This chapter

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Using Natural Experiments to Evaluate

Population-level PA Interventions with Children: A

Systematic Review

Introduction

Engaging in regular PA during childhood is associated with numerous health benefits and

protects against risk factors associated with obesity (Janssen & LeBlanc, 2010; Shaibi et al.,

2008). According to Canadian recommendations (Janssen & LeBlanc, 2010; Tremblay et al.,

2010), to obtain the health benefits associated with PA, children should have at least 60 minutes

of moderate to vigorous activity (MVPA) every day. Unfortunately, only 9% of Canadian

children (age 5-17) meet Canada’s recommended guidelines of 60 minutes of MVPA on most

days of the week (Shields, 2006; Tremblay et al., 2010; ParticipACTION, 2016).

The decline in children’s PA has generated considerable interest in assessing and

promoting PA among children, as obesity rates have almost tripled among Canadian children in

the last three decades (Colley et al., 2011; Chaput et al., 2012; Janssen et al., 2005). Reasons for

the decline in children’s PA is complex, as this behaviour is influenced by a range of factors at

multiple levels of influence from intrapersonal and interpersonal, to community and policy

(Bauman et al., 2012; Sallis et al., 2000; Van Der Horst et al., 2007). A number of

socio-demographic factors such as age, sex, ethnicity, socio-economic status (SES), and immigrant

status have been identified as underlying determinants of PA in children (Brodersen et al., 2007;

Bryan et al., 2006; Colley et al., 2011; Sallis et al., 2000; Singh et al., 2008). Children’s

interpersonal networks have also been found to influence PA behaviour, as several studies

suggest that social support from parents and peers positively influence PA in children (Beets et

al., 2006; Duncan et al., 2005; Trost & Loprinzi, 2011; Welk, Wood, & Morss, 2003). On a

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levels of PA. As a number of correlates of PA in children have been identified, it becomes

crucial to assess the effectiveness of interventions aimed at increasing PA.

This paper aims to establish the current state of evidence related to naturally-occurring

population-based PA interventions with children by conducting a systematic review. This study

addresses the following objectives: 1) to summarize and evaluate previous literature by exploring

the methods and measures that have been used in evaluations, 2) to examine the associated PA

outcomes, and 3) to identify factors that influence the success of PA interventions. The

information generated in this review will inform researchers and policy-makers about relevant

evidence-based strategies to modify PA at a population-level.

2.1.1. Measuring Physical Activity

Due to the unique nature of children’s PA, there are a variety of different measures that

have been used to assess PA in children, with each measure possessing distinct advantages and

disadvantages (Trost, 2007; Warren et al., 2010). Measures used to assess PA can be

characterized as either objective measures (i.e., heart-rate monitor, accelerometers, pedometers)

or subjective measures (i.e., self-report, direct observation). In recent years, the use of

accelerometers has increased dramatically, as it is an attractive device due to its small size,

modest cost and is a viable measure to use with children and adolescents (Sylvia et al., 2015;

Trost, 2007). Accelerometers provide an objective measure of PA by assessing the body during

movement by capturing the frequency, duration and intensity of movement (Strath et al., 2013;

Trost, 2007). In terms of subjective measures, self-reports continue to be the most widely used

due to the ease of administration, low cost, and convenience for large sample sizes (Trost, 2007).

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Determining the most appropriate measure to quantify PA in children presents a number of

challenges for researchers, as there is usually a trade off between the accuracy and practicality of

a measure (Welk et al., 2000). Understanding this trade off is particularly important for

developing and testing PA interventions.

2.1.2. Community-Based Interventions

Interventions are often used to test different theories, strategies and methods in hopes of

achieving positive PA outcomes. Over the last 20 years there has been a dramatic increase in the

number of PA interventions on children (van Sluijs et al., 2016). Despite the large scope of

research, reviews on the effectiveness of PA interventions have demonstrated limited efficacy for

changing children’s overall PA levels ( Kahn et al., 2002; Metcalf et al., 2012; van Sluijs et al.,

2007). Community-based PA interventions are suggested to be the most effective approach with

the greatest potential to achieve population-level change in children’s PA levels (Pate et al.,

2000; Sallis et al., 2008). Considering the amount of time children spend outside of school, the

community setting can promote leisure time PA by increasing opportunities for PA within the

community (Brand et al., 2014; van Sluijs et al., 2011; Perry et al., 2012). A number of

community-based interventions involve cross-sector collaborations with community groups,

academic institutions, organizations, recreation facilities, schools and policy-makers (Pate et al.,

2000; Sallis et al., 2008). This collaborative approach towards developing and implementing

community-based interventions also allow for greater reach of target groups, pooled resources,

and a more secure foundation for long-term sustainability (Bopp & Fallon 2008).

2.1.3. Natural Experiments

Community-based PA interventions have the potential to achieve population-level

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independently. To overcome this issue, researchers can evaluate already occurring interventions

as a ‘natural experiment,’ where individuals in experimental conditions are determined by nature

or factors outside the control of the researchers (Craig et al., 2012; Petticrew et al., 2005). For

instance, outcomes of interest can be examined between populations newly exposed to policies

or environmental changes with those unexposed (intervention and comparison groups), or

compare changes within the same population before and after a program or policy is initiated

(pre-post observations) (Mayne et al., 2015). To illustrate, Fuller et al. (2013) used a natural

experiment to determine if a bicycle share program increases the likelihood of biking in

Montreal, Quebec based on residential exposure. This approach is often a useful way of

understanding the impact of large-scale interventions on health outcomes that may not be

possible to study as a controlled experiment (Craig et al., 2012). As a result, natural experiments

produce good external validity that other research designs are unable to achieve, as they provide

evidence for the direct impact of an intervention in real-world settings (Craig et al., 2012;

Giles-Corti et al., 2015; Glasgow et al., 2004; Hunter et al., 2014; Petticrew et al., 2005; Ramanathan

et al., 2008). There are inherent limitations that exist with this approach, notably, the many

sources of potential bias such as confounding and threats to causal inference that should be taken

into consideration when measuring study outcomes (Craig et al., 2012).

While it is still a relatively underused tool in PA interventions with children, an

increasing number of studies have utilized a natural experimental approach, particularly in

environmental interventions that target active travel or built environment changes (Benton et al.,

2016; Carlin et al., 2016; Sallis et al., 2006). However, the utility of a natural experimental

approach for evaluating population-level PA interventions is not well understood, as there are no

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a need to not only assess PA outcomes, but also gather evidence on the methodologies currently

used to better understand how natural experiments can be effectively used to evaluate

population-based PA intervention with children.

Methods

2.2.1. Eligibility Criteria

A systematic review was conducted to identify articles published since 2000 that examine

naturally-occurring population-level PA interventions with children to determine the current

methods and measures used to evaluate PA, assess PA outcomes, and identify successful and

unsuccessful components of the studies and what external factors influence PA outcomes.

Eligible studies were selected by searching electronic databases (as of March 2016) and

reference lists of relevant articles. Various combinations of several search terms were used in

order to capture relevant articles (i.e., physical activity, play, children, youth, intervention,

natural experiment, evaluation, community, population). Search terms were inputted into four

electronic databases: PubMed, Web of Science, Sport Discus, and Engineering Village

(GEOBASE, Inspec, and Compendex). The selected databases cover a range of fields from social

science, health, engineering, and applied science.

2.2.2. Search Strategy and Selection of Studies

Articles were included if they met the following criteria: published between 2000-2016;

focused on children or adolescents (between 6-18 years); conducted community- or

population-based interventions; the intervention or program was naturally-occurring; PA was the primary

outcome variable (i.e., objective or subjective measure); and articles were written in English. For

the purpose of this review, the terms community- and population-based interventions are

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population of children. For example, a community or population for an intervention could be a

single school or neighbourhood, or as large as a city. This allowed for a greater spectrum of

articles that used a natural experimental approach. Similarly, the age range used for inclusion of

articles was broad in order to capture all relevant interventions that targeted school-aged children

that used a natural experimental approach. Interventions were considered to be

naturally-occurring if the article stated that the program or intervention was initiated by an external agency

and it was not under the direct control of the researchers.

Articles were excluded based on the following criteria: focused on pre-school ages,

adults, or a clinical population (i.e., obese children); examined the general population with no

distinct analyses for children, or a subset of population (i.e., only girls); were family-based,

school-based, or primary care interventions; and studies that primarily focused on nutrition.

Some school-based interventions were included if it was clear that PA was taking place outside

of school hours or if schools were used as the method of recruitment and data collection.

The initial search returned 9,496 articles (see Figure 2.1). The titles of all the articles

were screened and a total of 3,556 potentially relevant articles were identified. The title

screening resulted in 6,140 articles being excluded, of which 510 were duplicates. Abstract

screening resulted in the exclusion of 2998 articles. Of the remaining 558 articles, the full text

was reviewed and 458 were deemed not to satisfy inclusion criteria. Of the remaining 100

articles, 88 were removed, as they did not meet the definition of a natural experiment. Finally,

reviewing the reference lists of the relevant articles identified an additional 3 articles. A total of

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2.2.3. Data Extraction

Data on the study design, study location, total sample size, sample age, year of

publication, PA domain, PA measures, intervention components, evaluation components and

findings were extracted for each article that met the inclusion criteria and tabulated (see

Appendix A at the end of the chapter). Since the purpose of this review is to determine how

naturally-occurring population-based PA interventions have been evaluated, outcomes associated

with PA, physical fitness, or anthropometric measures related to PA (i.e., body composition,

BMI) were reviewed. Additional outcomes related to evaluation components and external factors

were also reviewed.

Evidence Synthesis

2.3.1. General Characteristics of the Reviewed Studies

A total of 15 papers were reviewed. A majority of the studies were conducted in the

United States (11/15), while Australia, New Zealand, United Kingdom and Canada had one

study each. Sample sizes ranged from 55 to 7455. Nine of the studies were conducted with

children (ages 6-12 years), five studies included both children and adolescents, and only one

study targeted only adolescents (ages 13-18 years). Among the reviewed studies, duration of the

study period varied from 5 weeks to 3 years. Only five of the studies reported the use of a

theoretical framework or approach for the intervention that included social cognitive theory,

social ecological framework, social marketing principles and an infrastructure/capacity building

approach. In terms of the types of PA examined, five studies focused on active travel, five

studies targeted built environment, three studies conducted interventions aimed at general PA,

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Active travel interventions typically focused on promoting walking or biking to and from

school either through walking school bus programs or safe routes to school programs. Of the

built environment studies, three involved park renovations and two included more

comprehensive changes throughout the community such as the creation of sidewalks, crosswalks,

walking trails, and bike racks. All three studies targeting general PA were part of the same

intervention (VERB), a mass media campaign based on social marketing principles that

promoted PA as cool, fun, and easy. One of these studies adapted VERB into a summer program

and partnered with community-based organizations to offer PA opportunities. The two studies

that used after-school settings both involved adapting programing to include a new PA

component in local community organizations; one study partnered with the YMCA, and the other

study included the YMCA and Boys and Girls Club in delivering the intervention.

PA was generally measured using subjective measures as eight of the studies used only

subjective measures and seven studies used a combination of subjective and objective measures.

Eleven studies included an additional evaluation component in tandem with evaluating the

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Table 2.1 General characteristics of the papers reviewed.

General Characteristics of the Papers Reviewed

Characteristics of Paper Number of Articles

Study Design

Quasi-experimental

Repeated cross-sectional (control group) 6 Longitudinal (control group) 4 Longitudinal (no control group)a ₁

Cross-sectional (control group) 1 Non-experimental

Longitudinal (no control group) 2 Repeated cross-sectional (no control group) 1

Total Sample Size

1-100 3

101-500 6

500+ 6

Geographic Origin

Australia 1

Canada 1

New Zealand 1

UK 1

United States 11

Theory or Framework Used

Social cognitive theory 2 Social ecological framework 1 Alternative approaches 2

Not reported 10

Age Group

Children (6-12) 10

Adolescent (13-18) 1

Both 5

PA Domain

Active travel 5

After school 2

Built environment 5

General PA 3

PA Measures

Objective 1

Subjective 9

Both 5

Evaluation Measures

PA only 4

Other evaluation component 11

Note: a _{One study created control group based on participants exposure level to the}

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2.3.2. Types of Methods and Measures Used

The studies identified in the literature search used several types of research designs. Of

the 15 studies, the most frequently used was a quasi-experimental research design with pre/post

measures (12/15). Of these 12, a majority of the studies included a control group for except one

study that used a statistical technique to create a control group based on participant’s exposure to

the intervention (Huhman et al. 2005). Three of the studies used a non-experimental research

design that included pre/post measures (but no control group). Eight of the studies used a

cross-sectional study design where different individuals were assessed at pre/post measurement

periods, and the other seven studies used longitudinal study design to assess the same individuals

at pre/post measurement periods.

Common among population-based PA interventions, almost half of the studies used only

self-report measures to obtain PA outcomes (7/15) (see Table 2.2). Self-reports included child

surveys such as the national Youth Risk Behaviour Survey (YRSB) and the Youth Media

Campaign Longitudinal Survey (YMCLS). The YRBS is a biennial survey conducted by the

Center for Disease Control and Prevention (CDC) to monitor priority health risk behaviours of

adolescents nationwide (CDC, 2016), whereas the YMCLS is an interviewer-administered

telephone survey designed to evaluate the effects of the CDC VERB campaign. Both measures

have been found to have acceptable reliability (Brener et al., 2004; Welk et al., 2007). Other

studies that used self-report measures developed intervention specific questionnaires or used

classroom tallies. Five of the studies used accelerometers in combination with self-report

measures, four of which also included anthropometric measures. The only anthropometric

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Less frequently used was direct observation, as only three studies used this measure, two

of which used direct observation in combination with self-report. The direct observation

measures included System for Observing Fitness Instruction Time (SOFIT) and System for

Observing Play and Recreation (SOPARC). SOFIT is used to measure participants PA levels and

lesson context, whereas SOPARC is used to measure park user characteristics and PA behavior.

Table 2.2 Measurement characteristics of the reviewed papers

PA Measure Number of Papers

Subjective

Self-report 7

Direct observation 1

Objective

Anthropometry -

Accelerometer -

Combination

Self-report; Direct observation 2 Self-report; Accelerometer 1 Self-report; Accelerometer; Anthropometry 4

2.3.3. Physical Activity Outcomes

Given the range of measures used, outcome measures for PA were highly varied between

the studies and included MVPA, total daily PA, self-report of PA, direct observation of PA,

proportion of students who walked to school, and change in BMI. Overall, the studies showed

positive changes in PA outcomes. Based on the type of PA, the majority of positive outcomes

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Table 2.3 Results of the reviewed papers by physical activity domain

Authors Intervention PA Measure PA Outcome Results

Active Travel

Heelan (2005) Walking School Bus program: included 8 routes for the intervention schools

Self-report (School Index)

Accelerometer (ActiGraph)

BMI (kg/m2_{, age adjusted BMI}

percentiles, Lange skinfold calipers, % body fata₎

Prevalence of walking

MVPA

Changes in BMI, BMI percentile, skinfold thickness, and % body fat

↑ ↑ ↔

McKee (2016) Travelling Green: a school-based active travel project that included interactive tools

Mapping software (MapIt) Self-report survey

Distance travelled to school by walking

↑

Mendoza (2009) Walking School Bus program: included 3 routes for the intervention school

Self-report survey Proportion of students who

walked to school

↑

Sayers (2012) Walking School Bus program:

community volunteers meet and walk with children to school along scheduled routes fıve mornings per week before the beginning of the school day.

Accelerometer (ActiGraph) MVPA ↔

Stewart (2014) Safe Routes to School (SRTS) program: provides grants to projects in school-based communities that directly support walking and biking through:

engineering, education, encouragement, and evaluation.

SRTS project tracking database % of active travel ↑

After School

Gortemarker (2012)

YMCA After-school Food and Fitness Project: focused on program practice changes in the areas of physical activity and offered daily inclusive PA and promoted high levels of staff participation

Accelerometer (ActiGraph) MVPA, MPA, VPA ↑

Sharpe (2011) CATCH Kids Club: provided students

with opportunities to participate and practice skills in a variety of enjoyable physical activities